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Gender-based violence and violence against children are significant problems in South Africa. Community mobilisation and gender-transformative programming are promising approaches to address and reduce violence. A quantitative evaluation of One Man Can, a gender-transformative community mobilisation programme in South Africa, found mixed results in increasing gender-equitable behaviours and reducing violence. To better understand these findings, we analyse longitudinal qualitative data from community mobilisers, community members and community action teams, exploring individual and community-level factors that facilitate and hinder change. Interviews and focus groups were transcribed and analysed. Participants self-reported changes in their gender-equitable attitudes and use of violence as a result of participation in the programme, although some participants also reported opposition to shifting to a more gender-equitable culture. Facilitators to change included the internalisation of gender-transformative messaging and supportive social networks, which was buoyed by a shared vocabulary in their community generated by One Man Can. Because the programme targeted a critical mass of community members with gender-transformative programming, mobilisers and community action teams were held accountable by community members to model non-violent behaviour. Results reinforce the importance of addressing facilitators and barriers to change at both individual and community levels.

Community mobilization has been recognized as a critical enabler for HIV prevention and is employed for challenging gender inequalities. We worked together with community partners to implement the 'One Man Can' intervention in rural Mpumalanga, South Africa to promote gender equality and HIV risk reduction. During the intervention, we conducted longitudinal qualitative interviews and focus group discussions with community mobilizers (n = 26), volunteer community action team members (n = 22) and community members (n = 52) to explore their experience of being part of the intervention and their experiences of change associated with the intervention. The objective of the study was to examine processes of change in community mobilization for gender equity and HIV prevention. Our analysis showed that over time, participants referred to three key elements of their engagement with the intervention: developing respect for others; inter-personal communication; and empathy. These elements were viewed as assisting them in adopting a 'better life' and associated with behaviour change in the intervention's main focus areas of promoting gender equality and HIV risk reduction behaviours. We discuss how these concepts relate to the essential domains contained within our theoretical framework of community mobilization-specifically critical consciousness, shared concerns and social cohesion -, as demonstrated in this community. We interpret the focus on these key elements as significant indicators of communities engaging with the community mobilization process and initiating movement towards structural changes for HIV prevention.

Background: HPTN 084 compared the safety and efficacy of long-acting injectable cabotegravir (CAB) to daily oral TDF/FTC for prevention of HIV-1 in uninfected African women. Like a similar trial in MSM/TGW (HPTN 083), the trial was stopped early for efficacy, expediting the need to consider introduction strategies for different populations. We examine survey and qualitative data from a four-country sub-study to examine oral and injectable PrEP acceptability and considerations for CAB access among African women. Methods: Participants completed baseline and follow-up surveys on HIV risk perception, sexual behavior. product acceptability and adherence during the blinded trial. Additionally, up to two in-depth interviews each with 73 sub-study participants explored product use and trial-related experiences, during the blinded and unblinded study periods. Using survey data, we classified participants as: engaged in female sex work (FSW), having multiple non-transactional partners, or monogamous. A study statistician identified participants' assigned study arm. We followed a thematic analysis process to read transcripts, develop a codebook and apply codes in NVivo to transcripts with intermittent intercoder reliability checks; using Excel matrices to explore differences across risk categories and study arms. Findings: Participants overwhelmingly preferred injections to pills, appreciating the ease, convenience, and privacy of a long-acting formulation. Many participants described challenges with contraceptive and/or study pill adherence, impeded by late night work, unexpected travel, or heavy drinking. Women in the TDF/FTC arm were more likely to describe side effects, compared to those in the CAB arm. Pain also varied widely by study arm. When considering post-trial access to CAB, limited PrEP knowledge, cost and concerns around stigma and poor service quality were potential access barriers. Conclusion: Women's desire for privacy and ease of use outweighed injectable concerns, resulting in a strong preference for CAB. Cost and accessibility will need to be addressed by implementation programs. [ABSTRACT FROM AUTHOR]

While South Africa provides universal access to treatment, HIV testing and antiretroviral therapy (ART) uptake remains low, particularly among men. Little is known about community awareness of the effects of treatment on preventing transmission, and how this information might impact HIV service utilization. This qualitative study explored understandings of treatment as prevention (TasP) among rural South African men. Narratives emphasized the know value of ART for individual health, but none were aware of its preventive effects. Many expressed that preventing transmission to partners would incentivize testing, earlier treatment, and adherence in the absence of symptoms, and could reduce the weight of a diagnosis. Doubts about TasP impacts on testing and care included enduring risks of stigma and transmission. TasP information should be integrated into clinic-based counseling for those utilizing services, and community-based education for broader reach. Pairing TasP information with alternative testing options may increase engagement among men reluctant to be seen at clinics.

Introduction: Adolescent girls and young women (AGYW) who may benefit from HIV pre‐exposure prophylaxis (PrEP) face high levels of common mental disorders (e.g. depression, anxiety). Common mental disorders can reduce PrEP adherence and increase HIV risk, yet mental health interventions have not been well‐integrated into PrEP delivery. Methods: We conducted a four‐phase human‐centred design process, from December 2020 to April 2022, to understand mental health challenges among AGYW in Johannesburg, South Africa and barriers to integrated mental health and PrEP services. In the "Discover" phase, we conducted in‐depth interviews with AGYW and key informants (KIs) in Johannesburg. We conducted a rapid qualitative analysis, informed by the Consolidated Framework for Implementation Research (CFIR), to identify facilitators and barriers of integrated mental health and PrEP services and mapped barriers to potential implementation strategies. In the "Design" and "Build" phases, we conducted stakeholder workshops to iteratively adapt an evidence‐based mental health intervention, the Friendship Bench, and refine implementation strategies for South African PrEP delivery settings. In the "Test" phase, we piloted our adapted Friendship Bench package. Results: Interviews with 70 Discover phase participants (48 AGYW, 22 KIs) revealed the importance of integrated mental health and PrEP services for South African AGYW. Interviewees described barriers and implementation strategies for mental health and PrEP services around the CFIR domains: intervention characteristics (e.g. challenges with AGYW "opening up"); outer Johannesburg setting (e.g. community stigma); inner clinic setting (e.g. judgemental healthcare providers); characteristics of counsellors (e.g. training gaps); and the implementation process (e.g. need for demand creation). The Design and Build workshops included 13 AGYW and 15 KIs. Implementation barriers related to the quality and accessibility of public‐sector clinic services, lay counsellor training, and community education and demand creation activities were prioritized. This led to 12 key Friendship Bench adaptations and the specification of 10 implementation strategies that were acceptable and feasible in initial pilot testing with three AGYW. Conclusions: Using a human‐centred approach, we identified determinants and potential solutions for integrating mental health interventions within PrEP services for South African AGYW. This design process centred stakeholders' perspectives, enabling rapid development of an adapted Friendship Bench intervention implementation package. [ABSTRACT FROM AUTHOR]

Introduction: Stigma and disclosure concerns have been key barriers to oral pre-exposure prophylaxis (PrEP) adherence for African adolescent girls and young women (AGYW) in efficacy trials. We aimed to understand the impact of these factors among African AGYW in an open-label PrEP study. Methods: HPTN 082 was an open-label PrEP study among AGYW (ages 16 to 24) in Harare, Zimbabwe, and Cape Town and Johannesburg, South Africa from 2016 to 2018. Women starting PrEP were randomized to standard adherence support (counselling, two-way SMS, monthly adherence clubs) or standard support plus drug-level feedback. Serial in-depth interviews were conducted among 67 AGYW after 13-week and 26-week study visits to explore experiences of stigma, disclosure and PrEP adherence. We analysed data by coding transcripts and memo-writing and diagramming to summarize themes. Results: AGYW described stigma related to sexual activity (e.g. 'people say I'm a prostitute') and being perceived to be living with HIV because of taking antiretrovirals (e.g. 'my husband's friends say I'm HIV infected'). Participants who anticipated stigma were reluctant to disclose PrEP use and reported adherence challenges. Disclosure also resulted in stigmatizing experiences. Across all sites, negative descriptions of stigma and disclosure challenges were more common in the first interview. In the second interview, participants often described disclosure as an 'empowering' way to combat community-level PrEP stigma; many said that they proactively discussed PrEP in their communities (e.g. became a 'community PrEP ambassador'), which improved their ability to take PrEP and encourage others to use PrEP. These empowering disclosure experiences were facilitated by ongoing HPTN 082 study activities (e.g. counselling sessions, adherence clubs) in which they could discuss PrEP-related stigma, disclosure and PrEP adherence issues. Conclusions: Stigma and disclosure challenges were initial concerns for African AGYW newly initiating PrEP but many were empowered to disclose PrEP use over their first six months of PrEP use, which helped them cope with stigma and feel more able to take PrEP regularly. PrEP programmes can foster disclosure through community and clinic-based discussion, adherence clubs and activities normalizing sexual behaviour and PrEP use, which can reduce stigma and improve PrEP adherence and thus effectiveness. Keywords: Stigma; disclosure; HIV; pre-exposure prophylaxis; Africa; women, 1 | INTRODUCTION Daily oral pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) is >90% effective in preventing HIV when taken consistently [ ]. Adherence can be challenging, however, and [...]

: Introduction: HIV incidence remains high among African adolescent girls and young women (AGYW). The primary objective of this study is to assess pre‐exposure prophylaxis (PrEP) initiation, use, persistence and HIV acquisition among African AGYW offered PrEP in order to inform PrEP scale‐up. Methods: POWER was a prospective implementation science evaluation of PrEP delivery for sexually active HIV‐negative AGYW ages 16–25 in family planning clinics in Kisumu, Kenya and youth and primary healthcare clinics in Cape Town and Johannesburg, South Africa. Follow‐up visits occurred at month 1 and quarterly for up to 36 months. PrEP users were defined based on the month 1 refill. PrEP persistence through month 6 was assessed using Kaplan–Meier survival analysis among AGYW with a month 1 visit, defining non‐persistence as an ≥15 day gap in PrEP availability for daily dosing. PrEP execution was evaluated in a subset with PrEP supply from the prior visit sufficient for daily dosing by measuring blood tenofovir diphosphate (TFV‐DP) levels. Results: From June 2017 to September 2020, 2550 AGYW were enrolled (1000 in Kisumu, 787 in Cape Town and 763 in Johannesburg). Median age was 21 years, 66% had a sexual partner of unknown HIV status, and 29% had chlamydia and 10% gonorrhoea. Overall, 2397 (94%) initiated PrEP and 749 (31%) had a refill at 1 month. Of AGYW who could reach 6 months of post‐PrEP initiation follow‐up, 128/646 (20%) persisted with PrEP for 6 months and an additional 92/646 (14%) had a gap and restarted PrEP. TFV‐DP levels indicated that 47% (91/193) took an average of ≥4 doses/week. Sixteen HIV seroconversions were observed (incidence 2.2 per 100 person‐years, 95% CI 1.2, 3.5); 13 (81%) seroconverters either did not have PrEP dispensed in the study interval prior to seroconversion or TFV‐DP levels indicated Conclusions: In this study of PrEP integration with primary care and reproductive health services for African AGYW, demand for PrEP was high. Although PrEP use decreased in the first months, an important fraction used PrEP through 6 months. Strategies are needed to simplify PrEP delivery, support adherence and offer long‐acting PrEP options to improve persistence and HIV protection., INTRODUCTION African adolescent girls and young women (AGYW) have had HIV incidence rates of 4% in recent HIV prevention research cohorts [1–3]. Oral tenofovir‐based pre‐exposure prophylaxis (PrEP) confers >90% protection [...]

Background: Gender-based violence (GBV) undermines HIV prevention and treatment cascades, particularly among women who report partner violence. Screening for violence during HIV testing, and prior to offering pre-exposure prophylaxis (PrEP) to HIV uninfected women, provides an opportunity to identify those at heightened HIV risk and greater potential for non-adherence or early discontinuation of PrEP. The paper describes our experience with offering integrated GBV screening and referral as part of HIV counselling and testing. This component was implemented within EMPOWER, a demonstration project offering combination HIV prevention, including daily oral PrEP, to young women in South Africa and Tanzania.Methods: Between February 2017 and March 2018, a process evaluation was conducted to explore views, experiences and practices of stakeholders (study participants and study clinical staff) during implementation of the GBV screening component. This article assesses the feasibility and acceptability of the approach from multiple stakeholder perspectives, drawing on counselling session observations (n = 10), in-depth interviews with participants aged 16-24 (n = 39) and clinical staff (n = 13), and notes from debriefings with counsellors. Study process data were also collected (e.g. number of women screened and referred). Following a thematic inductive approach, qualitative data were analysed using qualitative software (NVivo 11).Results: Findings show that 31% of young women screened positive for GBV and only 10% requested referrals. Overall, study participants accessing PrEP were amenable to being asked about violence during HIV risk assessment, as this offered the opportunity to find emotional relief and seek help, although a few found this traumatic. In both sites, the sensitive and empathetic approach of the staff helped mitigate distress of GBV disclosure. In general, the delivery of GBV screening in HCT proved to be feasible, provided that the basic principles of confidentiality, staff empathy, and absence of judgment were observed. However, uptake of linkage to further care remained low in both sites.Conclusion: Most stakeholders found GBV screening acceptable and feasible. Key principles that should be in place for young women to be asked safely about GBV during HIV counselling and testing included respect for confidentiality, a youth-friendly and non-judgmental environment, and a functioning referral network. [ABSTRACT FROM AUTHOR]

Investigating how young women disclose oral pre-exposure prophylaxis (PrEP) use is important given evidence that disclosure is associated with higher adherence. We report qualitative results on PrEP disclosure among young women in South Africa and Tanzania who participated in a PrEP demonstration project (EMPOWER). In total, 81 in-depth interviews were conducted with 39 young women aged 16–24 years—25 from Johannesburg and 14 from Mwanza—at approximately 3, 6 and/or 9 months post-enrolment. Analysis of data was thematic and inductive. Most Johannesburg participants were students in the inner-city; in Mwanza, all worked in recreational venues, occasionally engaging in sexual transactions with customers. A continuum of approaches was evident. Partner disclosure was common in Johannesburg but less so in Mwanza, where many partners were feared as judgemental and potentially violent. In both sites, participants commonly disclosed to family to secure support, and to friends and work colleagues to advocate about PrEP and encourage uptake among at-risk peers. Adherence clubs appeared helpful in building participants' skills and confidence to disclose, particularly in gender-inequitable sexual relationships. PrEP counselling for young women should focus on strengthening communication skills and helping develop strategies for safe disclosure. [ABSTRACT FROM AUTHOR]

Qualitative interviews are increasingly being utilized within the context of intervention trials. While there is emerging assistance for conducting and reporting qualitative analysis, there are limited practical resources available for researchers engaging in a group coding process and interested in ensuring adequate Intercoder Reliability (ICR); the amount of agreement between two or more coders for the codes applied to qualitative text. Assessing the reliability of the coding helps establish the credibility of qualitative findings. We discuss our experience calculating ICR in the context of a behavioural HIV prevention trial for young women in South Africa which involves multiple rounds of longitudinal qualitative data collection. We document the steps that we took to improve ICR in this study, the challenges to improving ICR, and the value of the process to qualitative data analysis. As a result, we provide guidelines for other researchers to consider as they embark on large qualitative projects. [ABSTRACT FROM AUTHOR]

Background: Daily oral pre-exposure prophylaxis (PrEP) can reduce HIV infection in adolescent girls and young women if used consistently during periods of risk. The EMPOWER study evaluated peer-based clubs incorporating an empowerment curriculum offered to adolescent girls and young women (16-24 years) in South Africa and Tanzania for adherence support.Methods: Using serial in-depth interviews (n = 33), we assessed the benefits and challenges of club attendance among 13 EMPOWER participants in the Johannesburg site who were randomised to clubs. We used a summary matrix of coded data to support a narrative, case-based analysis. Four case studies are presented.Results: Club participants reported benefits such as increased self-esteem and self-efficacy, reduced isolation, and greater insight into gender-based violence and strategies to address it. Day-to-day PrEP adherence was not the only topic discussed in clubs; participants also appreciated the safe space for sharing problems (such as relationship conflict and PrEP stigma) and found interactive exercises helpful in improving partner communication.Conclusions: Findings support the use of peer-based clubs using a structured empowerment approach, which may offer valuable PrEP initiation support to adolescent girls and young women in settings with high HIV and gender-based violence prevalence.Trial Registration: Pan African Clinical Trials Registry PACTR202006754762723 , 5 April  2020, retrospectively registered. [ABSTRACT FROM AUTHOR]

Young women in South Africa face elevated risk of HIV infection compared to male peers. Cash transfers may mitigate their risk for HIV; however, there is limited understanding of mechanisms of impact. We explored hope as one potential mechanism. Longitudinal qualitative analysis was used to explore how cash transfer recipients in the HPTN 068 study conceptualised hope and how the intervention influenced their hope over time. We found the intervention increased confidence, alleviated financial stressors and instilled in young women the belief that a better life, defined as being educated, independent and supportive to family, was attainable. Findings support hope as a critical outcome of cash transfer and other economic strengthening interventions.

Evidence on cash transfer interventions for HIV prevention in adolescent girls and young women is unclear and indicates that they may not work uniformly in all settings. Qualitative interviews were conducted with 22 girls and young women post-intervention to determine how a cash transfer study (HPTN 068) in South Africa was perceived to influence sexual behaviours and to explore mechanisms for these changes. Participants described how the intervention motivated them to increase condom use, have fewer partners, end risky relationships and access HIV testing services at local primary health clinics. Changes were attributed to receipt of the cash transfer, in addition to HIV testing and sexual health information. Processes of change included improved communication with partners and increased negotiation power in sexual decision-making. Economic empowerment interventions increase confidence in negotiating behaviours with sexual partners and are complementary to sexual health information and health services that provide young women with a foundation on which to make informed decisions about how to protect themselves.